MEDICAL INFORMATION FORM Emergency Contact Information In case of a medical emergency, the ACU Champions Sports Camps staff will contact the Emergency Contact(s) you designate below First Contact Name ____________________________________________ Relationship _________________ Home Phone ___________________ Cell Phone ___________________ Work Phone __________________ Address ____________________________________________________________________________________ City ______________________________________________State ____________ ZIP ___________________ Second Contact Name _________________________________________ Relationship _________________ Home Phone ___________________ Cell Phone ___________________ Work Phone __________________ Address ____________________________________________________________________________________ City ______________________________________________State ____________ ZIP ___________________ Authorization of Treatment and Medical Release Form In case of a medical emergency occurring during my participation in ACU Champions Sports Camps,
ACU (and its employees or agents) may (but is not obligated to) take any actions to secure whatever
treatment it considers to be warranted under the circumstances regarding my health and safety. Such
as do not create a special relationship between ACU and me. I agree to be solely responsible for any
costs related to that treatment. I hereby give permission to the medical personnel selected by the camp
director to order X-rays, routine tests or treatment; to release any records necessary for insurance
purposes; and to provide or arrange necessary related transportation for my child; and I agree to be
solely responsible for any costs related to that treatment. By signing my name below, I agree with terms
outline in the authorization and give permission for this form to be printed as proof for ACU’s use. I
certify that all of the information provided in the health history statement is correct as far as I know,
and the student herein described has permission to engage in all prescribed camp Activity. Camper’s Name/Signature ___________________________________________Date ___________________ Parent/Guardian Signature __________________________________________Date ___________________ Healthcare Provider Information Camper’s Name ____________________________________________Camp attending _________________ Name of Primary Care Physician ______________________________________________________________ Phone Number of PCP ______________________________________ Health Insurance Company _________________________________ Group ID No. ____________________ Medical History Information Medication Allergies (Check all that apply/or add) Any other allergies and/or Dietary Restrictions ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Please check all medical conditions that this student experiences or has experienced within the past year Camper’s Name _______________________________________ Medications Please list any and all medications this student will be taking during the hours of camp.
All medications should be delivered to ACU Champions Sports Camps staff upon check-in.
The designated medical personnel will administer medications as prescribed per parent’s/guardian’s
permission. Medicine will not be dispensed unless the following guidelines are met:
• Prescription medications must be in the original pharmacy-labeled container or the original manufacturer’s container, and must have the student’s name on the container. • Any doctor’s office samples must be accompanied by a signed physician prescription. • Please limit the amount of medication to only what is required for your student’s term at camp. • Our camp provides most common over-the-counter medications, which will be dispensed per parent’s/guardian’s permission for each camper. Please list all medications that will be administered at camp: Name of Medication Strength Frequency Special Instructions Has student been hospitalized in the past year? o Yes o NO If yes, please explain briefly: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Camper’s Name _______________________________________ Any additional concerns or conditions of which we should be aware? ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Special Education Services
ACU is dedicated to removing barriers and opening access for students with disabilities in compliance
with ADA and Section 504 of the Rehabilitation Act. If you have a disability that requires
accommodations, please complete a specific request below. Accommodations Needed ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Please submit form by way of • Check-in site at 120 Moody Coliseum
• Mail to (Camp Name), ACU Box 27916, Abilene, Texas 79699-7916
THE OFFICIAL SUMMER SPORTS CAMPS OF
Patient Name: ________________________________________________________ NEW PATIENT MEDICAL HISTORY FORM -07/2010 Are you Right handed Left Handed both/ambidextrous Your family doctor is ___________________their office is in the city and state of ______________ What caused your pain? CAR ACCIDENT WORKERS COMP OTHER _______________ Please draw on the figure where the pain